376600647-11-18-2024-20-CC-ANGN-DB5UXX-20241118145903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376600647
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:59:10 PM

Document Has Been Signed on 11/18/2024 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	CAMPO KUMEYAAY HEAD START		FACILITY NUMBER:	376600647
ADMINISTRATOR/ DIRECTOR:	CRYSTAL KREMENSKY		FACILITY TYPE:	850
ADDRESS:	39639 OLD HIGHWAY 80		TELEPHONE:	(619) 473-9022
CITY:	BOULEVARD	STATE: CA	ZIP CODE:	91905
CAPACITY: 40	TOTAL ENROLLED CHILDREN: 34	CENSUS: 29	DATE:	11/18/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:10 AM
MET WITH:	Lari Haney		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On November 18, 2024, at 11:10 a.m., Licensing Program Analysts (LPAs), Angela Nguyen and Vicky Williamson conducted an unannounced Annual/ Random Inspection and met with Site Supervisor, Lari Haney. LPA disclosed the purpose of the inspection and toured the indoors and outdoors of the facility. This is a full day program that operates following the yearly schedule of Mountain Empire Unified School District. The facility has two classrooms in operation. The following ratios were observed: Preschool Room 1 (serves 2-year-olds) with 10 children, two (2) teachers and one (1) assistant. Preschool Room 2 (serves ages 3-5 years old) was observed on the playground with 19 children, one (1) teachers and two (2) assistant present. Facility operates Monday through Friday from 8:00 a.m. to 4:00 p.m. Furniture and equipment are in good condition. Floors in the facility are clean and safe. Toilets and hand-washing equipment are in safe and sanitary operating condition. Paper towels and toilet paper are available. The bathroom is lighted and has ventilation. Disinfectants, cleaning solutions and other hazardous items were made inaccessible to children during time of inspection. Kitchen, food preparation and storage areas are clean, free of litter/rubbish. Solid waste storage containers have tight fitting covers and are in good repair. Playground equipment is in safe condition. The surface of the outdoor activity space is maintained in a safe condition and free of hazards. Facility has smoke and carbon monoxide detectors that meet requirements. The last fire drill was conducted and documented on 9/26/2024. Earthquake drill was conducted and documented on 10/12/2024. Site supervisor stated that there are no swimming pools or other bodies of water on the premises. Site Supervisor stated that there are no firearms or ammunition allowed or stored on the premises. The facility provides breakfast, lunch, and snack. Children bring their own water bottles and filter drinking water is available at the facility. Menus are posted monthly.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Angela Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CAMPO KUMEYAAY HEAD START	FACILITY NUMBER: 376600647
	VISIT DATE: 11/18/2024

NARRATIVE

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Site Supervisor was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. Site Supervisor, Lari Haney stated that all employee’s working at this state preschool have received criminal record clearance with the Mountain Empire Unified School District.

Capacity and limitations as specified on the license are being maintained. Children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than eight (8) children in care. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility. The name of the facility representative and the fully qualified teacher designated to act in the facility representative’s absence has been reported to the Department. LPA reviewed facility sign in /sign out sheets. Facility utilizes a physical sign in/ out sheet. Site Supervisor was reminded that the person who signs the child in and out of the facility shall use their full legal signature and record the time of day. A review of the facility sign in/out sheet for Child #1 (C1) and Child #2 (C2) included the time but no signature for the authorized representative. LPA reviewed a sample of children’s files and observed files to be complete. LPA reviewed a sample of staff files and determined they were incomplete. Staff #1 (S1) did not have health screening report on file. S1 and Staff #2 (S2) did not have tuberculosis test results on file.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).
LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Angela Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CAMPO KUMEYAAY HEAD START	FACILITY NUMBER: 376600647
	VISIT DATE: 11/18/2024

NARRATIVE

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Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

LPA discussed with Site Supervisor, Title 22 Regulation 101229, Responsibility for Providing Care and Supervision. LPAs provided a copy of the regulation. Site Supervisor stated that she understood the regulation.

Site Supervisor was reminded to advise Licensee Representative, Crystal Kremensky to submit the following documents within 30 days: LIC 308 Designation of Responsibility, LIC 309 Administrative Organization, LIC 610 Emergency Disaster Plan , LIC 999 Facility Sketch, LIC 200A Child Care Center Application.

LPA and Site Supervisor discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, Resources, Mandated Reporter Training, California Megan’s Law (www.meganslaw.ca.gov), Lead Poisoning Facts, Forms and Regulations.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Per California Code of Regulations, Title 22, Division 12 & Chapter 1, deficiencies are being cited on the attached LIC 809-D.

A Technical Violation was issued Sign In and Sign Out 101229.1.

An exit interview was conducted and report was reviewed with the Site Supervisor, Lari Haney . A copy of their appeal rights (LIC 9058) and notice of site visit (LIC 9213) was provided. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. LPA observed Notice of Site Visit posted on bulletin board in lobby.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Angela Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

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Document is an Amendment of Original Document on 12/31/2024 10:41 AM

Created By: Angela Nguyen On 11/18/2024 at 02:07 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: CAMPO KUMEYAAY HEAD START	FACILITY NUMBER: 376600647
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	Deficiency removed per H&S section 1596.8716(a).
	POC Due Date:
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4	Deficiency removed per H&S section 1596.8716(a).
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Tulam Vu

LICENSING EVALUATOR NAME:

Angela Nguyen

LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC809 (FAS) - (06/04)

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